Publications

Abstract

The withdrawal, withholding, or implementation of life-sustaining treatments such as artificial nutrition and hydration challenge nurses on a daily basis. To meet these challenges, nurses need the composite skills of moral and ethical discernment, practical wisdom and a knowledge base that justifies reasoning and actions that support patient and family decision making. Nurses' moral knowledge develops through experiential learning, didactic learning, and deliberation of ethical principles that merge with moral intuition, ethical codes, and moral theories. Only when a nurse becomes skilled and confident in gathering empiric and ethical knowledge can he or she fully act as a moral agent in assisting families faced with making highly emotional decisions regarding the provision, withholding, or withdrawal of artificial nutrition and hydration.

Abstract

Objective: To investigate aspects of nurses' work environments linked with job outcomes and assessments of quality of care in an Icelandic hospital. Background: Prior research suggests that poor working environments in hospitals significantly hinder retention of nurses and high quality patient care. On the other hand, hospitals with high retention rates (such as Magnet hospitals) show supportive management, professional autonomy, good inter-professional relations and nurse job satisfaction, reduced nurse burnout and improved quality of patient care. Methods: Cross-sectional survey of 695 nurses at Landspitali University Hospital, Reykjavík. Nurses' work environments were measured using the nursing work index-revised (NWI-R) and examined as predictors of job satisfaction, the Maslach burnout inventory (MBI) and nurse-assessed quality of patient care using linear and logistic regression approaches. Results: An Icelandic adaptation of the NWI-R showed a five-factor structure similar to that of Lake (2002). After controlling for nurses' personal characteristics, job satisfaction, emotional exhaustion and nurse rated quality of care were found to be independently associated with perceptions of support from unit-level managers, staffing adequacy, and nurse-doctor relations. Conclusions: The NWI-R measures elements of hospital nurses' work environments that predict job outcomes and nurses' ratings of the quality of patient care in Iceland. Efforts to improve and maintain nurses' relations with nurse managers and doctors, as well as their perceptions of staffing adequacy, will likely improve nurse job satisfaction and employee retention, and may improve the quality of patient care.

Abstract

Objective - There is increasing physiological evidence in rodents connecting the neuropeptide galanin to triglyceride (TG) levels. We hypothesized that variation in the galanin preproprotein (GAL) gene may contribute to hypertriglyceridemia (HTG) in humans. Methods and Results - We investigated GAL as a TG candidate gene by genotyping 4 tagSNPs in Dutch, Finnish, and Mexican familial combined hyperlipidemia (FCHL) families as well as in white combined hyperlipidemia cases/controls (n=2471). The common allele of rs2187331, residing in the promoter region of GAL, was significantly associated with HTG (probability value=0.00038). In an unascertained population sample of 4463 Finnish males, the rare allele of rs2187331 was associated with higher TGs (probability value=0.0028 to 0.00016). We also observed an allele specific difference with rs2187331 in reporter gene expression and nuclear factor binding in vitro. Furthermore, we detected differential expression of many key lipid genes in adipose tissue based on rs2187331 genotypes. Conclusions - The SNP rs2187331 is associated with HTG in FCHL and white combined hyperlipidemia cases/controls and influences TG levels in the population. Further studies are warranted to elucidate the allelic difference observed between FCHL and the general population. Functional evidence shows that rs2187331 has an allele specific cis-regulatory function and influences the expression of lipid related genes in adipose.

Abstract

Background: Despite a common view that women are better at self-care, there is very little evidence to support or challenge this perspective in the heart failure (HF) population. Objective: The purpose of this study was to determine if there are cross-cultural gender differences in self-reported HF self-care and to describe gender differences in the determinants of HF self-care. Design, setting, and participants: A secondary analysis was completed of cross-sectional study data collected on 2082 adults with chronic HF from the United States, Australia and Thailand. Methods: Comparisons were made between men and women regarding self-care maintenance, management and confidence as assessed by the Self-Care of Heart Failure Index, as well as the proportion of subjects engaged in adequate self-care. Multivariate comparisons were made to determine if gender explained sufficient variance in HF self-care and the likelihood of reporting adequate self-care, controlling for nine model covariates. Results: The sample was comprised of 1306 men and 776 women. Most (73.5%) had systolic or mixed systolic and diastolic HF and 45% had New York Heart Association class III or IV HF. Although small and clinically insignificant gender differences were found in self-care maintenance, gender was not a determinant of any aspect of HF self-care in multivariate models. Married women were 37% less likely to report adequate self-care maintenance than unmarried women. Comorbidities only influenced the HF self-care of men. Being newly diagnosed with HF also primarily affected men. Patients with diastolic HF (predominantly women) had poorer self-care maintenance and less confidence in self-care. Conclusion: Differences in HF self-care are attributable to factors other than gender; however, there are several gender-specific determinants of HF self-care that help identify patients at risk for practicing poor self-care.

Abstract

Purpose:Research suggests that men and women often differ in knowledge and beliefs about causes and treatments of a variety of diseases. This study examines gender differences in views about cognitive health and behaviors that have been associated with its maintenance, focusing on older adults living in rural areas.Design and Methods:We conducted 6 focus groups in rural West Virginia. Participants included 37 women and 30 men, aged 55 years and older.Results:Men and women held similar views of cognitive decline, as well as largely similar views about causes of Alzheimer's disease (AD). However, women were more concerned about developing AD than were men. Gender differences were also noted with respect to healthy lifestyle beliefs, including diet, leisure-time physical activity, and strategies to maintain cognitive health.Implications:Findings illustrate the importance of considering gender with respect to health beliefs, health behaviors, and health promotion, and emphasize the need to develop interventions designed for specific populations. Results highlight a critical need to translate research findings to the community.

Abstract

Purpose:Evidence suggests that physical activity and healthy diets may help to maintain cognitive function, reducing risks of developing Alzheimer's disease and vascular dementia. Using a cross-cultural focus, we describe older adults' awareness about cognitive health, and their ideas about how to inform and motivate others to engage in activities that may maintain brain health.Design and Methods:Nineteen focus groups were conducted in 3 states (California, North Carolina, South Carolina) with 177 adults aged 50 years and older. Six groups were with African Americans (AAs), 4 with Chinese, 3 with Vietnamese, 4 with non-Hispanic Whites, and 2 with American Indians (AIs). A qualitative thematic analysis was conducted.Results:Many participants did not recall reading or hearing about brain health in the media. Participants recommended a multimedia approach to inform others about brain health. Both interpersonal and social/group motivational strategies were suggested. Word of mouth and testimonials were recommended most often by Chinese and Vietnamese. AAs and AIs suggested brain health education at church; AAs, Chinese, and Vietnamese said brain health slogans should be spiritual. Participants' perceived barriers to seeking brain health information included watching too much TV and confusing media information.Implications:Findings on communication strategies for reaching racial/ethnic groups with brain health information will help guide message and intervention development for diverse older adults.

Abstract

Background: Heart failure (HF) self-care is poor in developed countries like the United States, but little is known about self-care in developing countries. Methods and Results: A total of 2082 adults from 2 developed (United States and Australia) and 2 developing countries (Thailand and Mexico) were studied in a descriptive, comparative study. Self-care was measured using the Self-Care of HF Index, which provided scores on self-care maintenance, management, and confidence. Data were analyzed using regression analysis after demographic (age, gender, education), clinical (functional status, experience with the diagnosis, comorbid conditions), and setting of enrollment (hospital or clinic) differences were controlled. When adequate self-care was defined as a standardized score ≥70%, self-care was inadequate in most scales in most groups. Self-care maintenance was highest in the Australian sample and lowest in the Thai sample (P < .001). Self-care management was highest in the US sample and lowest in the Thai sample (P < .001). Self-care confidence was highest in the Mexican sample and lowest in the Thai sample (P < .001). Determinants differed for the three types of self-care (eg, experience with HF was associated only with self-care maintenance). Conclusion: Interventions aimed at improving self-care are greatly needed in both the developed and the developing countries studied.

Abstract

Screening and brief intervention (SBI) for alcohol reduction is an important health promoting strategy for patients with HIV, and HIV care providers are optimally situated to support their patients' reduction efforts. We report results from analyses that use data collected from providers (n=115) in 7 hospital-based HIV care centers in the New York City metropolitan area in 2007 concerning their routine use of 11 alcohol SBI components with their patients. Providers routinely implemented 5 or more of these alcohol SBI components if they (1) had a specific caseload (and were therefore responsible for a smaller number of patients), (2) had greater exposure to information about alcohol's effect on HIV, (3) had been in their present positions for at least 1 year, and (4) had greater self efficacy to support patients' alcohol reduction efforts. Findings suggest the importance of educating all HIV care providers about both the negative impact of excessive alcohol use on patients with HIV and the importance and value of alcohol SBIs. Findings also suggest the value of promoting increased self efficacy for at least some providers in implementing alcohol SBI components, especially through targeted alcohol SBI training.

Abstract

Although HIV care providers are strategically situated to support their patients' alcohol reduction efforts, many do not do so, sometimes failing to view this support as consistent with their roles. Using data collected from 112 HIV providers in 7 hospital-based HIV Care Centers in the NYC metropolitan area, this paper examines the correlates of providers' role legitimacy as patients' alcohol reduction supporters. Results indicate that providers (1) responsible for a very large number of patients and (2) with limited confidence in their own ability to give this assistance, but high confidence in their program's ability to do so, were less likely to have a high level of role legitimacy as patients' alcohol reduction supporters. Findings suggest the types of providers to target for alcohol reduction support training.

Abstract

Aim. The aim of the study was to investigate relationships between nurse practice environment, burnout, job outcomes and nurse-assessed quality of care. Background. A growing line of work confirms that, in countries with distinctly different healthcare systems, nurses report similar shortcomings in their work environments and the quality of care in hospitals. Neither the specific work environment factors most involved in dissatisfaction, burnout and other negative job outcomes, and patient outcomes, nor the mechanisms tying nurse job outcomes to quality of care are well understood. Method. A Nurse Practice Environment and Outcome causal structure involving pathways between practice environment dimensions and outcome variables with components of burnout in a mediating position was developed. Survey data from 401 staff nurses across 31 units in two hospitals (including the Revised Nursing Work Index, the Maslach Burnout Inventory, and job outcome and nurse-assessed quality of care variables) were used to test this model using structural equation modelling techniques. The data were collected from December 2006 to January 2007. Results. Goodness of fit statistics confirmed an improved model with burnout dimensions in mediating positions between nurse practice environment dimensions and both job outcomes and nurse-assessed quality of care, explaining 20% and 46% of variation in these two indicators, respectively. Conclusion. These findings suggest that hospital organizational properties, including nurse-physician relations, are related to quality of care assessments, and to the outcomes of job satisfaction and turnover intentions, with burnout dimensions appearing to play mediating roles. Additionally, a direct relationship between assessments of care quality and management at the unit level was observed.

Abstract

Human papillomavirus infection, the most common sexually transmitted infection in the United States, is associated with the development of cervical cancer. The new human papillomavirus vaccine advances cervical cancer prevention; however, provider-recommended screening with Papanicolaou tests and lifestyle modifications are still needed. Widespread implementation of the vaccine and delivering cervical cancer screening to underserved populations remain a challenge. Nurses are ideally suited to address these needs by providing education to patients and families.

Abstract

Objective: To examine whether second trimester biomarkers could be used to identify screen positive pregnancies at increased risk for congenital heart defects (CHDs) and measure the effect of using different biomarker cut points on the detection of CHDs and on the performance of predictive models. Methods: Included were 19,402 pregnancies without chromosomal defects, which were screen positive for Down syndrome or other birth defects based on maternal serum measurements of alpha-fetoprotein (AFP), human chorionic gonadotrophin (hCG), and unconjugated estriol (uE3). Logistic regression models were built that compared biomarkers for CHD cases compared to controls. Results: CHD cases were more likely to be screen positive for trisomy-18, to have a nuchal fold (NF) ≥5 mm, and/or to have an hCG multiple of the median (MoM) ≥95th percentile in models that considered screen positive grouping. In models that did not consider screen positive grouping, cases were more likely to have a NF ≥5 mm, an AFP MoM ≤10th percentile, an hCG MoM ≤25th percentile, and/or an hCG MoM ≥75th percentile. Conclusion: Along with NF, second trimester maternal serum biomarkers may be useful indicators for fetal and newborn evaluation for CHDs in screen positive pregnancies without identified chromosomal defects.

Abstract

Background: In the Rationing of Nursing Care in Switzerland Study, implicit rationing of care was the only factor consistently significantly associated with all six studied patient outcomes. These results highlight the importance of rationing as a new system factor regarding patient safety and quality of care. Since at least some rationing of care appears inevitable, it is important to identify the thresholds of its influences in order to minimize its negative effects on patient outcomes. Objectives: To describe the levels of implicit rationing of nursing care in a sample of Swiss acute care hospitals and to identify clinically meaningful thresholds of rationing. Design: Descriptive cross-sectional multi-center study. Settings: Five Swiss-German and three Swiss-French acute care hospitals. Participants: 1338 nurses and 779 patients. Methods: Implicit rationing of nursing care was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Other variables were measured using survey items from the International Hospital Outcomes Study battery. Data were summarized using appropriate descriptive measures, and logistic regression models were used to define a clinically meaningful rationing threshold level. Results: For the studied patient outcomes, identified rationing threshold levels varied from 0.5 (i.e., between 0 ('never') and 1 ('rarely') to 2 ('sometimes')). Three of the identified patient outcomes (nosocomial infections, pressure ulcers, and patient satisfaction) were particularly sensitive to rationing, showing negative consequences anywhere it was consistently reported (i.e., average BERNCA scores of 0.5 or above). In other cases, increases in negative outcomes were first observed from the level of 1 (average ratings of rarely). Conclusions: Rationing scores generated using the BERNCA instrument provide a clinically meaningful method for tracking the correlates of low resources or difficulties in resource allocation on patient outcomes. Thresholds identified here provide parameters for administrators to respond to whenever rationing reports exceed the determined level of '0.5' or '1'. Since even very low levels of rationing had negative consequences on three of the six studied outcomes, it is advisable to treat consistent evidence of any rationing as a significant threat to patient safety and quality of care.

Abstract

To explore factors throughout the lifespan that influence cognition in midlife to late life. Methods: We conducted a retrospective birth cohort study of 2,062 individuals born during 1921-1954 in Beijing, China. In 2003-2005, birth records were abstracted, and participants then 50-82 years old received standardized examinations for health, cognition, and socioenvironmental measures. Using cumulative logit models, we assessed adjusted relative effects of prenatal, early life, and adult factors on mid- to late-life cognition. Results: Most prenatal factors were associated with mid- to late-life cognition in the unadjusted models. However, when childhood and adult factors were sequentially added to the models, the impact of prenatal factors showed successive attenuation in effect size, and became insignificant. In contrast, early life factors remained significantly associated with mid- to late-life cognition even after full life-course adjustments. Specifically, those whose fathers had laborer vs professional occupations (odds ratio [OR] Laborer 1.74; 95% confidence interval [Cl]: 1.25-2.42) had poorer cognitive outcomes, while individuals who drank milk daily in childhood (OR 0.65; 95% Cl: 0.54-0.80), had more years of education (OR10.12 years 0.60; 95% Cl: 0.45-0.81; OR13-yrs 0.29; 95% Cl: 0.23-0.38), and were taller adults (ORheight ≥ SD 0.65; 95% Cl: 0.49-0.86) had better cognition. The high prenatal risk infants had similar patterns with a trend toward a stronger association between cognition and socioenvironmental factors. Conclusion: Mid- to late-life cognition is influenced by factors over the entire lifespan with the greatest impact coming from early life exposures. Nutrition, education, social, and family environment in early life may have a long-term impact on cognition in developing countries.

Abstract

Developing long-term care systems for the elderly has become an increasingly urgent policy issue in China, especially in rural areas. This article provides an overview of the current status of long-term care development in rural China and discussion on the future development of institutional care and its policy implications. Formal long-term care systems are emerging but remain in the preliminary stages of development. Several policy considerations and practical implications deserve further attention: increases in regional and national government funding, integration of long-term care with the acute health care system, and creating more multilevel and multifunctional LTC facilities with a well-trained and skilled workforce.

Abstract

Objectives: Cross-language qualitative research occurs when a language barrier is present between researchers and participants. The language barrier is frequently mediated through the use of a translator or interpreter. The purpose of this analysis of cross-language qualitative research was threefold: (1) review the methods literature addressing cross-language research; (2) synthesize the methodological recommendations from the literature into a list of criteria that could evaluate how researchers methodologically managed translators and interpreters in their qualitative studies; (3) test these criteria on published cross-language qualitative studies. Data sources: A group of 40 purposively selected cross-language qualitative studies found in nursing and health sciences journals. Review methods: The synthesis of the cross-language methods literature produced 14 criteria to evaluate how qualitative researchers managed the language barrier between themselves and their study participants. To test the criteria, the researcher conducted a summative content analysis framed by discourse analysis techniques of the 40 cross-language studies. Results: The evaluation showed that only 6 out of 40 studies met all the criteria recommended by the cross-language methods literature for the production of trustworthy results in cross-language qualitative studies. Multiple inconsistencies, reflecting disadvantageous methodological choices by cross-language researchers, appeared in the remaining 33 studies. To name a few, these included rendering the translator or interpreter as an invisible part of the research process, failure to pilot test interview questions in the participant's language, no description of translator or interpreter credentials, failure to acknowledge translation as a limitation of the study, and inappropriate methodological frameworks for cross-language research. Conclusions: The finding about researchers making the role of the translator or interpreter invisible during the research process supports studies completed by other authors examining this issue. The analysis demonstrated that the criteria produced by this study may provide useful guidelines for evaluating cross-language research and for novice cross-language researchers designing their first studies. Finally, the study also indicates that researchers attempting cross-language studies need to address the methodological issues surrounding language barriers between researchers and participants more systematically.

Abstract

Background: Preventing the onset of injecting drug use is an important public health objective yet there is little understanding of the process that leads to injection initiation. This paper draws extensively on narrative data to describe how injection initiation is influenced by social environment. We examine how watching other people inject can habitualise non-injectors to administering drugs with a needle and consider the process by which the stigma of injecting is replaced with curiosity. Method: In-depth interviews (n = 54) were conducted as part of a 2-year longitudinal study examining the behaviours of new injecting drug users. Results: Among our sample, injection initiation was the result of a dynamic process during which administering drugs with a needle became acceptable or even appealing. Most often, this occurred as a result of spending time with current injectors in a social context and the majority of this study's participants were given their first shot by a friend or sexual partner. Initiates could be tenacious in their efforts to acquire an injection trainer and findings suggest that once injecting had been introduced to a drug-using network, it was likely to spread throughout the group. Conclusion: Injection initiation should be viewed as a communicable process. New injectors are unlikely to have experienced the negative effects of injecting and may facilitate the initiation of their drug-using friends. Prevention messages should therefore aim to find innovative ways of targeting beginning injectors and present a realistic appraisal of the long-term consequences of injecting. Interventionists should also work with current injectors to develop strategies to refuse requests from non-injectors for their help to initiate.